Copyright © 2018 All Rights Reserved.
State of New York )
) ss
County of ____________ )
On the ____ [Day] day of ______________ [Month] in the year_______ [Year] before me, the
undersigned, personally appeared __________________________________ [Name(s) of
Individual(s)] personally known to me or proved to me on the basis of satisfactory evidence to
be the individual(s) whose name(s) is (are) subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that
by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of
which the individual(s) acted, executed the instrument.
Signature and office of individual taking acknowledgment